JH IM Board Review - Hypertension I Flashcards
1
Q
Hypertension is present in nearly …%?
A
30% of the general population.
2
Q
HTN definition:
A
BP > 140/90mmHg or higher (SBP>140 OR DBP>90 OR BOTH).
3
Q
Classification of BP:
A
Normal ==> <120 AND <80.
PreHTN ==> 120-139 OR 80-89.
STAGE 1 ==> 140-159 OR 90-99.
STAGE 2 ==> >160 OR >100.
4
Q
The classification of BP applies to …?
A
Patients NOT taking antihypertensives + WITHOUT acute illness (which may raise or lower BP).
==> Patients taking antihypertensive medication are considered to have HTN.
5
Q
If the SBP and DBP fall in different stages …?
A
The HIGHER stage is used.
==> A BP of 182/95 is categorized as stage 2.
6
Q
Prehypertension is a …?
A
RISK CATEGORY (not a disease).
==> High risk of progressing to actual HTN and should be targeted for lifestyle modifications.
7
Q
Hypertensive URGENCY:
A
Severe HTN WITHOUT ACUTE END-ORGAN DYSFUNCTION.
8
Q
There is NO AGREED-UPON BP that defines hypertensive URGENCY, although …?
A
Some sources use 180/120.
9
Q
What often contributes to elevated BP in patients with hypertensive urgency?
A
- Headache.
- Anxiety.
- Medication nonadherence.
10
Q
Hypertensive emergency implies …?
A
Elevated BP WITH ACUTE END-ORGAN DYSFUNCTION.
11
Q
Although hypertensive emergency is not defined by any specific level of BP, most patients have …?
A
BPs 180/120 of higher.
12
Q
Epidemiology of HTN:
A
- Affects more than 60 million Americans.
- MC modifiable CV risk factor.
- More prevalent among AFRICAN AMERICANS, who also experience more end-organ damage.
13
Q
There is a GRADED relationship between BP level and the incidence of …?
A
- Stroke.
- ESRD.
- HF.
- IHD.
14
Q
Younger than 50, what is the most important predictor of adverse cardiovascular outcomes?
A
DIASTOLIC BP.
15
Q
Older than 50, what is the most important predictor of adverse cardiovascular outcomes?
A
SYSTOLIC BP.
16
Q
The prevalence of HTN rises with age:
A
SBP rises continuously.
DBP rises until approximately age 50 and then DECLINES.
17
Q
ISOLATED SBP (SBP >140 and DBP <90) is …?
A
COMMON among the ELDERLY and is an IMPORTANT CV RISK FACTOR.
18
Q
BP is the product of cardiac output and peripheral vascular resistance.
A
Increased CO can play a role in the INITIATION OF HTN.
==> However, most patients with long-standing HTN have increased peripheral resistance with normal or diminished CO.
19
Q
In some “salt sensitive” patients, BP responds strongly to …?
A
Changes in sodium intake and extracellular fluid.
==> Salt sensitivity occurs more commonly among African Americans AND elderly.
20
Q
End-organ damage from HTN can affect the …?
A
- Kidneys.
- Heart.
- Vasculature.
- Brain.
- Eyes.
21
Q
HTN - CP:
A
Most patients are ASYMPTOMATIC.
==> Some have evidence of target organ damage at first presentation.
==> Occasionally, patients may present with hypertensive urgencies or emergencies.
22
Q
7 Manifestations in ACUTE end-organ damage in hypertensive emergency:
A
- Hypertensive encephalopathy.
- Intracranial hemorrhage.
- Unstable angina.
- Acute myocardial infarction.
- LV failure with pulmonary edema.
- Acute aortic dissection.
- Eclampsia.
23
Q
Hypertensive encephalopathy:
A
- Headache.
- Altered mental status.
- Seizures.
- Nausea, vomiting.
- Papilledema.
- Abnormalities on brain imaging.
24
Q
Intracranial hemorrhage:
A
- Headache.
- Altered mental status.
- Focal neurologic abnormalities.
- Hemorrhage on brain imaging.
25
Unstable angina:
1. Chest pain.
| 2. ECG abnormalities.
26
Acute myocardial infarction:
1. Chest pain.
2. ECG abnormalities.
3. Cardiac enzyme elevation.
27
LV failure with pulmonary edema:
1. Dyspnea.
2. Hypoxia.
3. Pulmonary congestion on chest imaging.
28
Acute aortic dissection:
1. Chest pain.
2. Syncope.
3. End-organ ischemia.
29
Eclampsia:
1. Proteinuria.
| 2. Seizures.
30
Clinical manifestation of CHRONIC target organ damage in HTN - 5 systems:
1. Heart.
2. Brain.
3. Eyes.
4. Vasculature.
5. Kidneys.
31
Clinical manifestation of CHRONIC target organ damage in HTN - Heart:
A. LV HYPERTROPHY ==> Enlarged PMI (point of maximum impulse) or S4 gallop/ Evidence of LVH on ECG or ECHO.
B. LV DYSFUNCTION ==> Signs/symptoms of CHF / Enlarged PMI or S3 gallop/ Systolic or diastolic dysfunction on ECHO.
C. CAD ==> Angina/ History of MI, PCI, CABG.
32
Clinical manifestation of CHRONIC target organ damage in HTN - Brain:
Cerebrovascular disease ==> Hx of stroke/ Carotid bruit.
33
Clinical manifestation of CHRONIC target organ damage in HTN - Eyes:
Retinovascular disease:
1. Arteriolar narrowing.
2. AV nicking.
3. Hemorrhage.
4. Exudates.
34
Clinical manifestation of CHRONIC target organ damage in HTN - Vasculature:
Atherosclerosis.
1. Claudication.
2. Diminished or absent pulses.
3. Renal or femoral bruits.
35
Clinical manifestation of CHRONIC target organ damage in HTN - Kidneys:
Hypertensive nephrosclerosis, ESRD.
1. Proteinuria or microalbuminuria.
2. Elevated serum Cr.
36
HTN - Dx and evaluation - Measurement of BP:
1. Allow pt to relax and sit quietly for more than 5 min.
| 2. The patient should also refrain from smoking or consuming caffeine for more than 30 min before BP measurement.
37
HTN - Dx and evaluation - Use an appropriate sphygmomanometer cuff size:
The bladder cuff should encircle 80% or more of the arm without overlapping.
==> Using a smaller cuff may yield falsely elevated readings.
38
The arm in which BP is measured should be ...?
Supported and relaxed at the level of the heart.
39
BP should be measured in both arms, and ...?
The higher of the 2 readings used.
40
At each clinical visit, the BP preferably should be taken at least ...?
TWICE in the arm with the HIGHER BP measurement.
==> The average BP should guide management.
41
2 methods to assess BP:
1. Auscultatory method ==> SBP is defined as the 1st appearance of the Korotkoff sounds, and DBP is defined as the disappearance of Korotkoff sounds.
2. Oscillometric method ==> Electronic BP measurement devices, which detect pressure fluctuations in the cuff.
==> This method is often preferred over the auscultatory method because it is not subject to human bias or error.
42
Elevated BP reading on 2 SEPARATE CLINICAL VISITS should be obtained before classifying a patient as hypertensive.
However, ...?
If BP is very high (SBP >180) on MULTIPLE READINGS at the initial visit, it is reasonable to start antihypertensive medications at that time.
43
In elderly patients, or when orthostatic hypotension is suggested, ...?
STANDING BP measurements should be taken.
44
Some pts may have marked discrepancy between BP measurements obtained at home and in the clinic:
1. Elevated BP in clinic with normal out-of-office readings ==> White-coat hypertension.
2. Elevated out-of-office BP with normal clinic readings is referred to as MASKED hypertension.
==> In EITHER CASE, home BP readings and/or 24h ambulatory BP monitoring should be obtained and used to guide management.
45
For DAYTIME home BP monitoring, HTN is defined as an average ...?
Average BP greater than 135/85.
46
For 24h BP monitoring (which includes readings taken during sleep), ...?
An AVERAGE BP greater than 130/80 is considered HYPERTENSIVE.
47
3 Goals in INITIAL evaluation of the hypertensive patient:
1. Assess for target organ damage.
2. Identify comorbidities.
3. Identify other cardiovascular disease risk factors.
48
Assess for target organ damage - Requires:
Comprehensive physical examination:
1. Vital signs.
2. Body mass index.
3. Cardiopulmonary systems.
4. Auscultation of the major blood vessels to identify bruits in the eyes, neurologic system, and limbs.
49
Identify comorbidities:
1. DM.
2. CKD.
3. Ischemic heart disease and cardiomyopathy.
50
Identify other cardiovascular disease risk factors:
1. Smoking.
2. Dyslipidemia.
3. Older age.
4. Obesity.
5. Physical inactivity.
6. Family history.
51
Assess for identifiable (secondary) causes of HTN:
1. Renal artery stenosis.
2. Pheochromocytoma.
3. Hyperaldosteronism.
4. Hypercortisolism.
52
Recommended lab tests for INITIAL evaluation:
1. Serum Cr, Na, K, Fasting glucose.
2. Urinalysis with microscopic examination.
3. Electrocardiogram (or echocardiogram).
4. Fasting lipid profile.
==> OPTIONAL: Serum calcium, TSH.
==> Screen for identifiable (secondary) causes of HTN.
53
Consider 2o HTN in the following scenarios:
1. Sudden onset of HTN in a previously normotensive pt.
2. Age, Hx, PEx, severity of HTN, or initial laboratory findings suggestive of a specific cause.
3. Recurrence of HTN in a previously well-controlled patient (nonadherence should also be considered).
4. HTN resistant to 3 or more drugs, including a diuretic.
54
SUBSTANCES that may cause or worsen the HTN:
1. Alcohol (use or withdrawal).
2. Amphetamines, cocaine.
3. OTC medications (decongestants, diet pills, NSAIDs).
4. Prescription medications (NSAIDs, OCPs, cyclosporine, EPO).
5. Supplements (ephedra).
6. Licorice (inhibits metabolism of endogenous cortisol to cortisone).
55
Other correctable causes of HTN:
1. Acute pain or stress in hospitalized or institutionalized patients.
2. OSA.
3. Hyperthyroidism or hypothyroidism.
4. CKD (caused by RENIN OVERSECRETION + Impaired sodium excretion).
5. COTA (very uncommon in adults).
56
COTA findings:
1. Delayed femoral pulses.
2. Diminished leg BP.
3. Rib notching on chest radiograph suggest this diagnosis, which is confirmed with CT or MRI.
57
COTA Tx:
Either surgery or angioplasty.
58
Renal artery stenosis - CP:
1. Sudden onset of significant HTN at older (>55) or younger (<30).
2. Abdominal bruits.
3. Patients with peripheral vascular disease.
4. Unexplained deterioration in renal function.
5. Consider FMD in young females.
==> UNUSUALLY LARGE DROP IN BP WITH ACEIs OR ARBs Tx.
59
Renal artery stenosis - Dx:
1. MRA ==> Highly sensitive, no contrast required.
2. CTA ==> Highly sensitive, contrast required.
3. Doppler US ==> Sensitivity operator-dependent, no contrast required.
4. Captopril radionuclide scan ==> LESS sensitive, requires discontinuation of antihypertensive medications before test.
5. Renal artery angiography ==> Gold standard, invasive, may be performed with CO2 to avoid use of iodinated contrast.
60
Renal artery stenosis - Tx:
Goal = To improve HTN control and measures to preserve renal function.
1. Revascularized patients usually still require medication for BP control.
2. STATINS decr. Progression.
3. The longer stenosis has been present, the less likely intervention will help (kidney becomes atrophic).
61
Interventional options:
1. Angioplasty +/- stent (lesions at ostia or renal arteries are often NOT amenable to angioplasty).
2. Surgical bypass.
3. Surgical excision of kidney if SIZE <8cm.
==> Medical therapy usually best if recovery of renal function is unlikely.
62
Pheochromocytoma - Pathophysiology:
1. Tumors that originate in the adrenal medulla or sympathetic ganglia and release catecholamines periodically.
2. Most are sporadic.
3. Familial forms (20-35%) are associated with:
==> MEN IIA/IIB, NF, VHL (with retinal angiomas, cerebellar hemangioblastomas and RCC).
63
Pheochromocytoma - CP:
1. Headache.
2. Sweating.
3. Palpitations.
4. Pallor.
5. Anxiety.
6. Weight loss.
7. Orthostatic hypotension.
8. HTN may be EPISODIC or SUSTAINED.
64
Pheochromocytoma - Dx:
1. Screen with plasma-free metanephrines, confirm with 24h urine collection for catecholamines, VMA, metanephrines.
2. Certain DRUGS may cause false(+) or false(-) screens.
3. If screen is positive ==> Localize with MRI (or MIBG scan if MRI negative).
65
Pheochromocytoma - Tx:
1. Surgical resection.
| 2. Preoperatively, patients should receive PHENTOLAMINE OR PHENOXYBENZAMINE to prevent crisis.
66
Hyperaldosteronism - Pathophysiology:
1. MCC of 2o hypertension.
2. Can be caused by an adenoma that produces aldosterone (Conn) or bilateral adrenal hyperplasia (zona granulosa).
3. Rarely can be caused by an aldosterone-producing CARCINOMA.
67
Hyperaldosteronism - CP:
1. Spontaneous HYPOKALEMIA in a hypertensive patient (may cause cramps and muscle weakness).
2. Severe HYPOKALEMIA induced by diuretics.
3. Mild metabolic ALKALOSIS.
68
Hyperaldosteronism - Dx:
1. Screen with plasma aldosterone and renin serum: ratio of aldosterone/renin >20 suggest disease.
2. Confirm by measuring 24h urine aldosterone after 3 days of salt loading: >12μg confirms diagnosis.
3. If screen positive, localize with CT or MRI; adrenal vein sampling.
69
Hyperaldosteronism - Tx:
1. Surgical resection of adenoma.
| 2. Treat with spironolactone for patients with hyperplasia.
70
Hypercortisolism - Pathophysiology:
Several possible causes:
1. Cushing disease.
2. Adrenal adenomas.
3. Ectopic ACTH secretion.
4. Iatrogenic steroid administration.
71
Hypercortisolism - Dx:
1. Screen with 24h urinary free cortisol OR salivary cortisol OR 1mg overnight dexamethasone suppression test.
2. If positive, perform high-dose dexamethasone suppression test and measure plasma ACTH.
3. Localize with imaging of adrenals or pituitary.
72
Hypercortisolism - Tx:
Surgical resection of tumor or discontinuation of steroid therapy.
73
Initial management of BP - Recommended follow-up:
Normal ==> Recheck in 2 years.
Prehypertension ==> Recheck in 1 year.
Stage 1 ==> Confirm within 2 months (provide advice about lifestyle modification).
Stage 2 ==> Evaluate or refer within 1 month.
>180 or >110 ==> Evaluate and treat immediately or within 1 week, depending on clinical situation and complications.
74
Suggested follow-up intervals should be SHORTER if ...?
Important risk factors (eg DM) or target organ damage is present.
75
Target BP goal is ...?
140/90 for ALL PATIENTS (incl. those with DM or CKD).
==> EXCEPT patients aged 60 or older without DM or CKD, who should be treated to a goal BP of 150/90.
76
Treatment recommendations by risk group - Normal:
Lifestyle modification ==> Encouraging.
Initial drug treatment ==> No compelling indication ==> None.
Initial drug treatment ==> Compelling indication(s) present ==> None.
77
Treatment recommendations by risk group - Prehypertension:
Lifestyle mod. ==> Yes.
Initial Dx ==> No compelling indication ==> None.
Initial Dx ==> Compelling indication ==> Appropriate drugs for DM, CKD, or CAD if BP >130/80, for HF if BP >120/80.
78
Treatment recommendation by risk group - Stage 1:
Lifestyle mod. ==> Yes.
Initial Dx ==> No compelling indication ==> Thiazide diuretic for most; may consider other drug classes.
Initial Dx ==> Compelling indication ==> Appropriate drug(s) for compelling indication.
79
Treatment recommendations by risk group - Stage 2:
Lifestyle modification ==> Yes.
Initial Dx ==> No compelling indication ==> 2-drug combination for most, including thiazide diuretic.
Initial Dx ==> 2-drug combination for most, usually including appropriate drug(s) for compelling indication.
80
Management recommendations - Always start with ...?
LIFESTYLE MODIFICATION even if drug therapy is also needed.
==> Recommend weight reduction of 10 pounds or more.
==> Encourage 30min or more of moderately intense physical activity (eg brisk walking) 4 or more times a week.
==> Counsel moderate alcohol intake (1 ounce or less/day in men, 1/2 ounce in women).
==> Recommend diet modifications.
81
Diet modifications:
1. Advise low sodium intake (100 mmol/day, ie 6g NaCl or 2.4g Na or less).
2. Recommend a diet high in fruits, vegetables, and low-fat dairy products: Dietary Approach to Stop Hypertension (DASH).
82
Smoking cessation?
Recommended.
==> NOT demonstrated to cause chronic hypertension.
83
Caffeine?
NO strong recommendation for altering caffeine intake.
==> Chronic caffeine intake not shown to correlate with elevated BP.
84
Relaxation therapy and stress management are of ...?
UNCERTAIN BENEFIT.
85
Drug therapy - General principles ==> INITIAL therapy:
1. General population (incl. those with DM) ==> A thiazide, CCB, ACEI, ARB, either alone or in combination (exception: do not use ACEIs and ARBs in combination).
2. General BLACK population ==> Including patients with DM ==> Thiazide, or CCB.
3. In patients with CKD ==> start either an ACEI or ARB.
86
In most cases, choose an agent with ...?
24h duration of action + once-daily dosing.
87
General principles - SUBSEQUENT therapy - Monotherapy:
Successful in approx. 40% of patients.
==> In approx. 60%, consider using 2 or more drugs to attain goal BP, especially in patients with a BP higher than 160/100.
88
If there is partial but inadequate response to the 1st antihypertensive drug, ...?
Either increase the dose or add a second agent from a different class.
89
If there is no response to the 1st drug or if the drug is not tolerated, ...?
Substitute a drug from a different class.
90
ALWAYS CONSIDER A DIURETIC IN ANY PATIENT ...?
NEEDING 3 OR MORE DRUGS.
91
Consider using low-dose combination therapy INSTEAD OF ...?
Higher doses of a single agent ==> to minimize dose-dependent side effects.
92
Formulations combining 2 or more drugs may offer improved convenience or lower cost, examples include:
1. Low-dose diuretics + ACEIs, ARBs, or beta-blockers.
2. Thiazides + K-sparing diuretics.
3. CCBs + ACEIs or ARBs.
4. 3-drug combinations containing a CCB + ACEI/ARB + Diuretic.
93
COMORBIDITIES can help guide choice of antihypertensive medication:
1. CKD ==> ACEI/ARB.
2. HF ==> ACEI/ARB, beta-blocker.
3. MI ==> Beta-blocker, ACEI, aldosterone antagonist.
4. Migraines ==> Beta-blocker, CCBs.
5. BPH ==> Alpha-blockers.
6. Essential tremor ==> Beta-blockers.
7. Hyperthyroidism ==> Beta-blockers (nonselective).
94
CONTRAINDICATIONS to certain antihypertensives with conditions/disease states:
1. Pregnancy ==> ACEIs and ARBs ARE ABSOLUTELY CONTRAINDICATED.
2. Asthma, COPD, PVD ==> Use beta blockers with caution.
3. Gout ==> Avoid or minimize dose of diuretics.
4. 1st or 2nd degree heart block ==> Avoid beta-blockers, verapamil, and diltiazem.
95
Contraindications to certain antihypertensives with conditions/disease states - Uncomplicated HTN:
1. Beta-blockers. UNLESS there is a specific indication such as CAD or HF.
==> Avoid beta-blockers unless diuretic, CCB, and ACEI or ARB therapy have all been tried.
2. Loop diuretics. Should be used only when thiazide diuretics are likely to be inadequate (ie CHF or stage 4 CKD).
==> Short-acting loop diuretics (furosemide, bumetanide) should be taken twice daily, or replaced with a long-acting diuretic (eg torsemide).
96
Tx - Hypertensive URGENCY:
1. Need prompt but gradual control of BP using oral agents.
2. Outpatient follow-up is appropriate, but needs BP assessment at least weekly.
3. Rapidly acting oral agents, such as clonidine, are not usually needed.
97
Tx - Hypertensive EMERGENCY:
1. BP must be brought down rapidly but in a controlled fashion in an ICU by administering IV antihypertensive medications, which have a rapid effect + are easily titratable.
2. Initial goal is to lower mean arterial BP by approx. 25%, but not more, within 2 hours.
3. Subsequent goal is to lower BP to approx. 160/100 over the next 2 to 24 hours (if aortic dissection is also present, reduce BP further as tolerated).
98
Antihypertensive agents - Classes:
1. Thiazides.
2. Loops.
3. K-sparing diuretics.
4. Beta-blockers.
5. ACEI/ARBs.
6. Alpha-blockers.
7. Nondihydropyridine CCBs.
8. Dihydropyridine CCBs.
9. Direct vasodilators.
10. Central adrenergic inhibitors.
99
Thiazides- Examples:
1. HTZ.
2. Chlorthalidone.
3. Indapamide.
100
Thiazides - Side effects:
1. Hypokalemia.
2. Hyponatremia.
3. Alkalosis.
4. Hyperuricemia.
5. Dehydration.
6. Hypercalcemia.
101
Thiazides - Comments:
Thiazides not effective if GFR <30mL/min.
==> Side effects rarely a problem at low doses.
102
Loops - Examples:
1. Furosemide.
2. Torsemide.
3. Bumetanide.
103
Loops - Side effects:
As for thiazides, EXCEPT FOR HYPERCALCEMIA.
104
Loops - Comments:
1. Furosemide and bumetanide have short half-lives.
2. Dose twice a day for HTN.
3. Sodium restriction should accompany diuretics.
105
K-sparing diuretics - Examples:
1. DISTAL tubule Na channel blockers: Triamterene, amiloride.
2. Aldosterone antagonists ==> Spironolactone, eplerenone.
106
K-sparing diuretics - Side effects:
1. Hyperkalemia.
2. Hyponatremia.
3. Dehydration.
107
K-sparing diuretics - Comments:
1. Often given in combination with thiazides (to prevent hypokalemia).
2. Avoid or use with caution in renal insufficiency.
108
Beta-blockers - Examples:
1. Beta-1 ==> Atenolol, metoprolol.
2. Non-beta-1 selective ==> Propranolol, nadolol.
3. Alpha-1 and beta-1 block ==> Carvedilol, labetalol.
109
Beta-blockers - Side effects:
1. Bradycardia.
2. Fatigue.
3. Insomnia.
4. Erectile dysfunction.
5. Bronchospasm in asthma and COPD patients.
110
Beta-blockers - Comments:
1. May mask hypoglycemic symptoms in diabetics.
2. Do NOT use alone in cases of catecholamine excess (cocaine, pheochromocytoma) as unopposed alpha-1 vasoconstrictrition without beta-2 vasodilation may increase BP precipitously.
111
Alpha blockers - Comments:
1. Block the postsynaptic alpha-1 receptors ==> Vasodilation.
2. Favorable effect on LIPID PROFILE and GLUCOSE LEVEL.
3. May INCREASE CHD mortality if used as a single agent.
112
Nondihydropyridine CCBs - Side effects:
1. Bradycardia.
2. Heart block.
3. Decr. Cardiac contraction.
4. Constipation.
113
Nondihydropyridine CCBs - Comments:
Verapamil may increase cyclospοrine and digoxin levels.
114
Dihydropyridine CCBs - Side effects:
1. Headache.
2. Flushing.
3. Tachycardia.
4. PEDAL EDEMA.
115
Dihydropyridine CCBs - Comments:
1. Dilate arterioles.
2. Possibly increase heart rate.
3. Short-acting nifedipine and nicardipine cause marked reflex tachycardia and are NOT RECOMMENDED for HTN.
4. NIFEDIPINE increases cyclosporine levels.
116
Direct vasodilators - Examples:
1. Minoxidil.
| 2. Hydralazine.
117
Direct vasodilators - Side effects:
1. Headache.
2. Tachycardia.
3. Fluid retention.
Minoxidil ==> Hirsutism, pericardial effusion.
Hydralazine ==> Dx-induced lupus.
118
Direct vasodilators are considered ...?
3RD LINE AGENTS.
119
Central adrenergic inhibitors - Examples:
1. Clonidine.
2. Guanfacine.
3. Reserpine.
4. Methyldopa.
120
Clonidine, guanfacine - Side effects:
1. Sedation.
2. Dry mouth.
3. Withdrawal hypertension.
121
Methyldopa - Side effects:
1. Coombs(+) hemolytic anemia.
| 2. Liver toxicity.
122
Central adrenergic inhibitors - Comments:
1. Inhibit sympathetic outflow from CNS.
2. Clonidine also available in patch.
3. Methyldopa safe in pregnancy.
123
Dx used in Tx of hypertensive EMERGENCY:
1. Nitroprusside ==> Most/ Thiocyanate tox.
2. Nitroglycerin ==> Angina, MI/ Headache, tolerance.
3. Nicardipine ==> Most/ Tachycardia.
4. Labetalol ==> Most/ CHF, Bradycardia.
5. Fenoldopam ==> Most/ Tachycardia.
6. Enalaprilat ==> CHF/ Rapid, unpredictable BP drop.
7. Esmolol ==> Perioperative, aortic dissection/ Nausea.
